Preoperative Patient Care A Outpatient Evaluation and Management 1 Obtains focused history and performs focused exam determine the mechanism of injury examine extremity for shortening, external rotation, and ipsilateral injuries check neurovascular status document presence of underlying osteoarthritis concomitant and associated orthopaedic injuries 2 Interpret basic imaging studies AP Pelvis, AP/Lat hip and femur for degree of fracture displacement 3 Interact with consultants regarding optimal patient management timing of surgery medical management assess risk for thromboembolic disease 4 Makes informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention 5 Provides post-operative management and rehabilitation postop: 2-3 week postoperative visit wound check diagnose and management of early complications staples/sutures removed continue physical therapy and range of motion exercises postop: ~ 3 month postoperative visit diagnosis and management of late complications postop: 1 year postoperative visit B Advanced Evaluation and Management 1 Comprehensive assessment of fracture patterns on imaging studies 2 Interpretation of diagnostic studies for fragility fractures with appropriate management and/or referral 3 Arranges for long term management of geriatric patients management of bone health discharge planning to long term care 4 Modifies and adjusts post-operative treatment plan as needed 5 Provides prohylaxis and manages thromboemblotic disease C Preoperative H & P 1 Obtain history and perform physical exam document distal neurovascular status identify patient comorbidities and ASA status (predictor of mortality) pre-injury mobility is the most significant determinant for post-op survival household ambulators with assistive devices, low demand patients are ideal for cemented hemiarthroplasty community ambulators without assistive devices may receive THA instead of hemiarthroplasty make sure patient has Foley urinary catheter in place elderly patients with hip fractures should be definitively managed as soon as medically cleared within 48-72h associated with decreased pulmonary complications, thromboembolic events, length of hospital stay, and morbidity/mortality 2 Order basic imaging studies order AP Pelvis, AP/Lat hip and femur 3 Perform operative consent and lists potential complications describe complications of surgery including describes pros and cons of nonoperative treatment superficial / deep infection mortality (14-36% at 1 year post-op) Operative Techniques E Preoperative Plan 1 Radiographic templating of fracture evaluate AP Pelvis, AP/Lat hip and femur for degree of fracture displacement 2 Execute surgical walkthrough describe the steps of the procedure to the attending verbally prior to the start of the case describe potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation hip cemented hemiarthroplasty system 2 Room setup and equipment standard OR table sterile hoods with circulating fans for surgical team hip positioners or bean bag check back table to make sure correct equipment available 3 Patient positioning lateral decubitus with operative extremity facing up axillary roll, anterior positioner on pubic symphysis, posterior positioner on sacrum, Foley in place in obese patients place towel or pad between positioners and skin check to make sure operative leg can be flexed to 90° with positioners in place arms stacked on top of each other with blankets underneath and in between, taped down to arm boards prep and drape entire leg above iliac crest and midline sacrum to make sure adequate working area bovie pad on contralateral thigh or abdomen foot in "candycane holder" and ankle stirrup with extremity externally rotated to prevent knee buckling during prep G Posterior Approach to the Hip 1 Mark out GT and anterior/posterior borders of femur and anterior bow of femur mark out the anatomy of GT 2 Mark incision posterior to midline of GT down shaft of femur incision is curved posterior to edge of GT, aimed towards PSIS proximally 1/3 of incision proximal to GT, 2/3 distal to GT (~10-15cm long) 3 Perform dissection use 10 blade for skin incision curve incision posterior aiming for posterolateral corner of GT incise fascia 2-3 cm with knife just posterior to midline of GT 4 Expose the fascia lata insert 2 self retainers (Wheatlanders, Oberhills for larger patients) at 1/3 and 2/3 aspect of incision cauterize bleeders in subcutaneous tissue use knife down to fascia lata 5 Develop fascial plane use Cobb and dry lap to sweep soft tissue abduct leg 30° to relax TFL place Hibbs retractor proximally 6 Incise fascia 2-3cm with knife just posterior to midline of GT start distal and move proximal with cautery H Deep Dissection of Posterior Approach to the Hip 1 Place Charnley retractor place the long blade anterior and the short blade posterior need to retract glut medius and minimus anteriorly while just glut max posterior 2 Split glut max with blunt dissection using index fingers in center of decussating fibers, expose trochanteric bursa on lateral margin of GT femoral neck fractures will often have hemorrhagic bursa and ill defined anatomy leg stays abducted until short external rotators (SERs) visualized internally rotate hip to place SERs on stretch 3 Dissect SERs with Bovie incise soft tissue and bursa off of posterior aspect of GT with leg extended to keep sciatic nerve out of field identify SERs (piriformis and obturator internus, gamelli) and quadratus distally (can often feel piriformis tendon proximally) dissect SERs directly off of bone with Bovie start distally just proximal to quadratus and move proximally extend proximally along posterior aspect of abductors, extend distally until quadratus femoris (will bleed due to medial femoral circumflex artery) sciatic nerve is located in fat deep to piriformis and superficial and posterior to SERs 4 Tag SERs with #5 ethibond place #5 Ethibond tag sutures (x3) into SERs and anterior capsule place hemostat on each pair grab enough soft tissue for repair later on 5 Release capsule release capsule using longitudinal or T-shaped incision 6 Dislocate hip use flexion, adduction and internal rotation leg perpendicular to ground, 90-90° I Femoral Head Extraction 1 Make preliminary neck cut use sagital saw to get more room to remove femoral head 2 Remove femoral head via corkscrew or ring shaped tenaculum cauterize soft tissue away and clean off with Cobb 3 Choose implant size use native femoral head to measure size for templating implant head size (typically 46-52mm) J Canal Preparation 1 Elevate the femur use proximal femoral retractor (double prong, equal prongs on either side) and place under GT to help elevate femur and protect soft tissues can use Hibbs or #1 acetabular retractor to get better calcar exposure 2 Make neck cut 0.5-1cm proximal to lesser trochanter use box cutter to start, then canal finder then lateralizing reamer to make sure you are down canal and not in varus 3 Broach up sizes from small to larger start at 10, then 11, 12 (typically 12-13 size stem final) want snug fit but don’t need to overtighten cement will fill void between implant and bone need to hit broaches with same power to evaluate if it’s advancing watch calcar for evidence of fracture place leg in extension and internal rotation to visualize the calcar 4 Trial implants extend the leg and hyper internal rotation to get max exposure of proximal femur, then heads, reduce with traction and external rotation 5 Check for stability, range of motion and leg lengths K Cement Insertion 1 Dislocate hip, remove trials, size and place cement restrictor (typically 11-12mm) place cement restrictor 15cm down from neck cut (length may vary depending on stem being used) 2 Clean and dry canal using epinephrine soaked sponge suction out canal 3 Insert cement in retrograde fashion pressurized with gun place sponge in acetabulum to block cement extrusion cement typically takes 3.5-4.5min to reach appropriate consistency for insertion 4 Cover tip of stem with extra cement L Final Implants 1 Use stem pusher and Tommy bar to control depth and anteversion place in 10-15° anteversion (angled posterior for increased anteversion) add 5-10° if worried about posterior dislocation hold in place until cement hard (~15min) 2 Trial head and neck size (typically +7, +10.5) engage Morse taper, allow cement to dry, and relocate hip 3 Confirm Implant Position and Extremity check final anteversion of stem and impingement, leg lengths, rotation when hip dislocates anterior and posterior N Wound Closure 1 Irrigation, hemostasis, and drain pulsatile irrigate acetabulum and deep tissues cauterize peripheral bleeding vessels 2 Deep closure repair short external rotators and capsular layer with #5 Ethibond figure of 8 sutures tie to either glut medius anteriorly or through bone on posterior aspect of GT close TFL with #1 Ethibond figure of 8 sutures 3 Superficial closure need use 3-0 vicryl for subcutaneous tissue use 3-0 nylon for skin 4 Dressing and immediate immobilization soft incision dressings over hip Postoperative Patient Care O Perioperative Inpatient Management 1 Write comprehensive admission orders IV fluids DVT prophylaxis pain control advance diet as tolerated foley out when ambulating check appropriate labs wound care change dressings POD2 2 Appropriate medical management and medical consultation 3 Initiate physical therapy POD1 weight-bearing as tolerated, physical therapy posterior hip precautions 4 Discharges patient appropriately pain meds DVT prophylaxis schedule follow up appointment in 2weeks outpatient PT R Complex Patient Care 1 Develops unique, complex post-operative management plans
A Outpatient Evaluation and Management 1 Obtains focused history and performs focused exam determine the mechanism of injury examine extremity for shortening, external rotation, and ipsilateral injuries check neurovascular status document presence of underlying osteoarthritis concomitant and associated orthopaedic injuries 2 Interpret basic imaging studies AP Pelvis, AP/Lat hip and femur for degree of fracture displacement 3 Interact with consultants regarding optimal patient management timing of surgery medical management assess risk for thromboembolic disease 4 Makes informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention 5 Provides post-operative management and rehabilitation postop: 2-3 week postoperative visit wound check diagnose and management of early complications staples/sutures removed continue physical therapy and range of motion exercises postop: ~ 3 month postoperative visit diagnosis and management of late complications postop: 1 year postoperative visit B Advanced Evaluation and Management 1 Comprehensive assessment of fracture patterns on imaging studies 2 Interpretation of diagnostic studies for fragility fractures with appropriate management and/or referral 3 Arranges for long term management of geriatric patients management of bone health discharge planning to long term care 4 Modifies and adjusts post-operative treatment plan as needed 5 Provides prohylaxis and manages thromboemblotic disease C Preoperative H & P 1 Obtain history and perform physical exam document distal neurovascular status identify patient comorbidities and ASA status (predictor of mortality) pre-injury mobility is the most significant determinant for post-op survival household ambulators with assistive devices, low demand patients are ideal for cemented hemiarthroplasty community ambulators without assistive devices may receive THA instead of hemiarthroplasty make sure patient has Foley urinary catheter in place elderly patients with hip fractures should be definitively managed as soon as medically cleared within 48-72h associated with decreased pulmonary complications, thromboembolic events, length of hospital stay, and morbidity/mortality 2 Order basic imaging studies order AP Pelvis, AP/Lat hip and femur 3 Perform operative consent and lists potential complications describe complications of surgery including describes pros and cons of nonoperative treatment superficial / deep infection mortality (14-36% at 1 year post-op)
E Preoperative Plan 1 Radiographic templating of fracture evaluate AP Pelvis, AP/Lat hip and femur for degree of fracture displacement 2 Execute surgical walkthrough describe the steps of the procedure to the attending verbally prior to the start of the case describe potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation hip cemented hemiarthroplasty system 2 Room setup and equipment standard OR table sterile hoods with circulating fans for surgical team hip positioners or bean bag check back table to make sure correct equipment available 3 Patient positioning lateral decubitus with operative extremity facing up axillary roll, anterior positioner on pubic symphysis, posterior positioner on sacrum, Foley in place in obese patients place towel or pad between positioners and skin check to make sure operative leg can be flexed to 90° with positioners in place arms stacked on top of each other with blankets underneath and in between, taped down to arm boards prep and drape entire leg above iliac crest and midline sacrum to make sure adequate working area bovie pad on contralateral thigh or abdomen foot in "candycane holder" and ankle stirrup with extremity externally rotated to prevent knee buckling during prep G Posterior Approach to the Hip 1 Mark out GT and anterior/posterior borders of femur and anterior bow of femur mark out the anatomy of GT 2 Mark incision posterior to midline of GT down shaft of femur incision is curved posterior to edge of GT, aimed towards PSIS proximally 1/3 of incision proximal to GT, 2/3 distal to GT (~10-15cm long) 3 Perform dissection use 10 blade for skin incision curve incision posterior aiming for posterolateral corner of GT incise fascia 2-3 cm with knife just posterior to midline of GT 4 Expose the fascia lata insert 2 self retainers (Wheatlanders, Oberhills for larger patients) at 1/3 and 2/3 aspect of incision cauterize bleeders in subcutaneous tissue use knife down to fascia lata 5 Develop fascial plane use Cobb and dry lap to sweep soft tissue abduct leg 30° to relax TFL place Hibbs retractor proximally 6 Incise fascia 2-3cm with knife just posterior to midline of GT start distal and move proximal with cautery H Deep Dissection of Posterior Approach to the Hip 1 Place Charnley retractor place the long blade anterior and the short blade posterior need to retract glut medius and minimus anteriorly while just glut max posterior 2 Split glut max with blunt dissection using index fingers in center of decussating fibers, expose trochanteric bursa on lateral margin of GT femoral neck fractures will often have hemorrhagic bursa and ill defined anatomy leg stays abducted until short external rotators (SERs) visualized internally rotate hip to place SERs on stretch 3 Dissect SERs with Bovie incise soft tissue and bursa off of posterior aspect of GT with leg extended to keep sciatic nerve out of field identify SERs (piriformis and obturator internus, gamelli) and quadratus distally (can often feel piriformis tendon proximally) dissect SERs directly off of bone with Bovie start distally just proximal to quadratus and move proximally extend proximally along posterior aspect of abductors, extend distally until quadratus femoris (will bleed due to medial femoral circumflex artery) sciatic nerve is located in fat deep to piriformis and superficial and posterior to SERs 4 Tag SERs with #5 ethibond place #5 Ethibond tag sutures (x3) into SERs and anterior capsule place hemostat on each pair grab enough soft tissue for repair later on 5 Release capsule release capsule using longitudinal or T-shaped incision 6 Dislocate hip use flexion, adduction and internal rotation leg perpendicular to ground, 90-90° I Femoral Head Extraction 1 Make preliminary neck cut use sagital saw to get more room to remove femoral head 2 Remove femoral head via corkscrew or ring shaped tenaculum cauterize soft tissue away and clean off with Cobb 3 Choose implant size use native femoral head to measure size for templating implant head size (typically 46-52mm) J Canal Preparation 1 Elevate the femur use proximal femoral retractor (double prong, equal prongs on either side) and place under GT to help elevate femur and protect soft tissues can use Hibbs or #1 acetabular retractor to get better calcar exposure 2 Make neck cut 0.5-1cm proximal to lesser trochanter use box cutter to start, then canal finder then lateralizing reamer to make sure you are down canal and not in varus 3 Broach up sizes from small to larger start at 10, then 11, 12 (typically 12-13 size stem final) want snug fit but don’t need to overtighten cement will fill void between implant and bone need to hit broaches with same power to evaluate if it’s advancing watch calcar for evidence of fracture place leg in extension and internal rotation to visualize the calcar 4 Trial implants extend the leg and hyper internal rotation to get max exposure of proximal femur, then heads, reduce with traction and external rotation 5 Check for stability, range of motion and leg lengths K Cement Insertion 1 Dislocate hip, remove trials, size and place cement restrictor (typically 11-12mm) place cement restrictor 15cm down from neck cut (length may vary depending on stem being used) 2 Clean and dry canal using epinephrine soaked sponge suction out canal 3 Insert cement in retrograde fashion pressurized with gun place sponge in acetabulum to block cement extrusion cement typically takes 3.5-4.5min to reach appropriate consistency for insertion 4 Cover tip of stem with extra cement L Final Implants 1 Use stem pusher and Tommy bar to control depth and anteversion place in 10-15° anteversion (angled posterior for increased anteversion) add 5-10° if worried about posterior dislocation hold in place until cement hard (~15min) 2 Trial head and neck size (typically +7, +10.5) engage Morse taper, allow cement to dry, and relocate hip 3 Confirm Implant Position and Extremity check final anteversion of stem and impingement, leg lengths, rotation when hip dislocates anterior and posterior N Wound Closure 1 Irrigation, hemostasis, and drain pulsatile irrigate acetabulum and deep tissues cauterize peripheral bleeding vessels 2 Deep closure repair short external rotators and capsular layer with #5 Ethibond figure of 8 sutures tie to either glut medius anteriorly or through bone on posterior aspect of GT close TFL with #1 Ethibond figure of 8 sutures 3 Superficial closure need use 3-0 vicryl for subcutaneous tissue use 3-0 nylon for skin 4 Dressing and immediate immobilization soft incision dressings over hip
O Perioperative Inpatient Management 1 Write comprehensive admission orders IV fluids DVT prophylaxis pain control advance diet as tolerated foley out when ambulating check appropriate labs wound care change dressings POD2 2 Appropriate medical management and medical consultation 3 Initiate physical therapy POD1 weight-bearing as tolerated, physical therapy posterior hip precautions 4 Discharges patient appropriately pain meds DVT prophylaxis schedule follow up appointment in 2weeks outpatient PT R Complex Patient Care 1 Develops unique, complex post-operative management plans